A Shot at Youth: The Truth About Injectables

Admit it, you're curious about Botox--and the many other anti-aging potions you can get with the prick of a needle. Theresa O'Rourke, an injectables virgin, susses out the good, the bad, and the truth.

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At a recent cocktail party, some women I'd just met were comparing notes about how fabulous they felt at 40-whatever. I smiled and listened, until the redhead beside me playfully nudged my elbow: "Why mourn our 30s, am I right?" It's a sentiment I would've gladly toasted... except I'm still in my 30s. Suddenly miserable, I knocked back the last of my sauvignon blanc and excused myself. I have no desire to pass for 25, or even 30. But jeez, I don't want to look over my age either. And as a longtime beauty writer, I shouldn't: Sunscreen is my BFF (I wear broad-spectrum SPF 30 every day), and I feel naked if I go to bed without slathering on my retinol serum and peptide-packed cream. Still, I have a few forehead creases that simply won't budge. I'd long suspected that they made me appear older--and now I had the proof, albeit from a tipsy stranger with no filter. Should I simply accept my lines, or tackle them with a new battle plan?

Many women are asking the same question, and they're finding answers at the business end of a needle. Injectables are easily the most popular cosmetic procedures in the country. More than 2.6 million people got Botox last year, up 7 percent from 2010. Hyaluronic-acid fillers are the second most requested, at 1.2 million last year. Meanwhile, many cosmetic surgical procedures (as in face-lifts) and non surgical ones (things like chemical peels and laser hair removal) are either flat or down. So who's fueling the surge? Women like me: married, working moms who, according to the American Society of Aesthetic Plastic Surgery, want to look "more relaxed."

These cosmetic-lite measures have obvious appeal: They take off a reasonable number of years in minutes, they cost far less than cosmetic surgery, and they require virtually no downtime. To me, however, they're still a big financial commitment, and I already spend enough on my beauty upkeep. (I could probably list my hair colorist as a dependent on my tax return.) But perhaps my biggest fear is this: Could that first shot be some sort of gateway drug? I can imagine the infomercial: People who bought Botox for crow's-feet... also enjoyed cheek and lip fillers. "We've all seen the overdone women--the blown-up lips, the oddly shaped cheeks, the frozen faces," says D'Anne Kleinsmith, M.D., a cosmetic dermatologist in Bloomfield, MI. "Many women fear that these unnatural-looking results are the norm, but they're not." Okay, but what exactly is the norm, and are the results worth it? To find out, I cross-examined top board-certified doctors from around the country, talked to scores of women who've had the procedures, and got my hands on every study I could find about the satisfaction rates. So if you, like me, are a sane, slightly vain woman who's wondered about going under the needle, this is your deep-dive guide to injectables.

How do injectables work?

There are dozens of space-age-sounding names for injectables, but they basically boil down to two types. Neurotoxins (i.e., Botox, Dysport, and Xeomin) block nerve impulses so facial muscles relax and stop contracting, no longer causing creases. Dermal fillers (including hyaluronic acids like Restylane and calcium-based fillers such as Radiesse) treat deeper wrinkles and folds as well as sagging, which happens when you lose collagen under the skin. Some can also plump lips and restore fullness to the face. "Women who use injectables tend to start with muscle relaxers to soften fine lines in their 30s, and move on to fillers in their 40s or 50s, if needed," says Ken Beer, M.D., a cosmetic dermatologist in West Palm Beach, FL.

When and if you start also depends on the kind of wrinkles you have. Lines that make you look permanently sad, tired, or annoyed may truly merit an injectable intervention. "I looked like Donald Trump, always scowling," says Sandra Kircher*, a 44-year-old businesswoman in Hillsborough, NJ, who now gets Botox between her brows. "The lines just kept getting deeper, even though I wear sunscreen every day and use rich moisturizers." But there are good wrinkles too. "Crow's-feet are smile lines and are connected with happiness and warm feelings," says Dee A. Glaser, M.D., a cosmetic dermatologist in St. Louis. "Why would you want to erase them?"

Like most anti-aging treatments, it helps to start injections on "bad" lines sooner rather than later, because the less engraved they are, the fewer treatments you'll need. Even if you've gotten injections in the past and decided to stop, you'll most likely be in a better place than where you began, says Paul M. Friedman, M.D., a cosmetic dermatologist in Houston. That's because fillers help skin regenerate natural collagen, "and neurotoxins like Botox help retrain your muscles so they don't crease as much." Elizabeth Tanzi, M.D., a cosmetic dermatologist in Washington, DC, concurs: "A woman with fine lines could try what I call 'baby Botox.' It's a smaller dosage of the toxin that prevents wrinkles from etching, while still allowing for plenty of facial movement." In fact, Kleinsmith says she's seen patients with fine lines who only needed one round of Botox, no repeats. "But they're typically in their early 30s," she admits. Christina Lowden, a 42-year-old yoga instructor in Trinity, FL, missed that window. "At 40, I got Botox to smooth my brow lines, but by then they were too deep for it to really work," she says. Though the Botox, which she still gets, helped stop new wrinkles from forming, Lowden ended up getting Restylane to fill in the old ones.

When you add it up, these procedures are an investment. (For prices, see the chart at right.) Some good news for your wallet, though: Injectables have dropped in price thanks to increased competition from newer brands. And many of the women I spoke with said they're able to eke out more mileage from each injection, because their results last longer than expected. (To find out how long most injectables last, see the chart.) "I only go for Botox twice a year--sometimes I can push it to every seven months," says Kircher. And Lowden says her Restylane has lasted well over a year.

What to expect when they're injecting

Techniques and formulas may be improving, but hey, we're still talking needles here, and for some, minimally invasive is still invasive. "It's amazing how much the pain threshold varies from patient to patient," says Friedman. Many of the women I interviewed described Botox injections as an annoying pinch and fillers as a deeper "burning" sensation. Sherry Wilson, 44, who's had Juvéderm injected into her nasolabial folds, says it stung like crazy, "and I heard a squishing noise, which was weird." Despite being mildly agitated by these side effects, she still goes back regularly, adding: "The discomfort is well worth the results." Most fillers are mixed with lidocaine, a numbing agent, to lessen the pain, and you can ask your doctor to apply a topical numbing cream first. Botox injections have another possible side effect: "My first time, it gave me the worst headache you could imagine," says Kircher. "But the subsequent injections weren't nearly as bad, and by the fourth time, I felt almost nothing."

Another key difference between the two types of injectables: You see results with most fillers immediately, while muscle relaxers don't take effect for about two weeks. "Honestly, the biggest pain about Botox is getting the scheduling right," says Elena Mitchell, 33, who had her forehead injected a week before her 15th high school reunion. "It took 12 days for the wrinkles to totally soften. In the end, I loved the results. But if I had it to do over again, I would've scheduled it three weeks before the event."

Also, take the "lunchtime procedure" notion with a grain of salt. Yes, you'll be in and out of the doctor's office in 20 minutes, but "you can definitely tell that you've had something done--I get red bumps and black-and-blue marks at the injection sites that last a few hours," Lowden says. So you may want to book your appointment for the end of the day.

How to get the best possible results

In the grand scheme of things, a little redness and bruising is no biggie (hello, concealer). But more serious complications can arise when injections aren't done properly, and that's why--and I can't stress this enough--you must go to a board-certified doctor. If you do, the chances of something going wrong are almost zilch. RealSelf.com, a consumer review and information site for cosmetic procedures, regularly polls its audience on the "worth it" rating of a particular procedure. Botox has a 93 percent "worth it" rating, and Restylane is even higher, at 97 percent. But when the site factors in women who didn't go to a board-certified doctor, those numbers plummet to 66 percent and 61 percent, respectively. You'll also typically get a more thorough consultation with a board-certified doctor--a crucial step in the injectables process. (To learn what else you need to do, see our checklist below.)

How much can go wrong with an inexperienced doctor? Plenty. If not injected deeply enough in the skin, fillers can cause lumps, which may require enzyme injections to shrink. The most troubling side effect of neurotoxins like Botox, according to a report by the FDA, is "lack of intended cosmetic effect." Translation: The practitioner likely injected too much, causing a frozen face or overarched brow, or didn't inject the solution at the proper points, which may result in droopy eyelids. Laura McLaughlin, an account executive in Indiana, experienced the latter. The 45-year-old went to a plastic surgeon her friend had recommended to smooth the area between her brows. But "a nurse administered the Botox instead of the doctor," she says. Five days later, her left eyelid drooped so badly it covered almost her entire eye. "When I returned, the doctor blew it off and said I'd have to wait it out. There was no apology, no refund. I'd paid a lot of money to look worse than before." The drooping lasted for six weeks, though iopidine eye drops (prescribed by another doctor) helped lift the lid some in the interim.

The feel-good factor

Just as swiping on lip gloss can instantly make you feel sexy, injectables can have sweet psychological perks. The journal Dermatologic Surgery published a study that found Botox patients report higher self-esteem in social settings and better performance at work. Also compelling, if a little strange: When the same researchers showed people before-and-after photos of women who'd had Restylane and Juvéderm, the women were perceived as more attractive, more successful in their relationships, and even as having more money post-injection. "It's been a huge mood- and confidence-booster," says Dana Santas, a 39-year-old yoga trainer in Tampa, FL, who gets Botox and Juvéderm. "I spend less time in the mirror judging myself, which has reduced my negative self-talk."

Most patients are healthy realists like Dana, but extremists exist as well: the movie stars and Real Housewives who become so obsessed with eradicating every single line that their frozen foreheads shine like an ice-skating rink. But experts say the chances of a sane, practical non-celeb becoming that obsessed are quite low. Who is susceptible? "If a person has body-image issues, such as body dysmorphic disorder, it could trigger a compulsive desire to get more treatments before the current injections have worn off," says David Sarwer, Ph.D., a professor of psychology at the Center for Human Appearance at the University of Pennsylvania.

To keep your own expectations in check, you need to know what injectables can and can't do. "Patients who have the highest satisfaction with injections already feel good about their lives--they're simply bothered by a few stubborn lines," says Sarwer. "A red flag goes up when a woman thinks these procedures will help her secure a promotion or spice up her marriage." Injectables aren't a DeLorean that can whisk you back in time, either. "You can't expect to take off 20 years or create high cheekbones that you never had to begin with," Tanzi cautions. "The goal should be to replace some, not all, of what you've lost."

Indeed, the best results are undramatic and almost imperceptible. No one should say, "Hey, did you have something done?" Of the women and dermatologists I spoke with, the most frequent comments after getting injections were about their hair or skin, or just that they looked rested and happy. Sherry, who gets Botox and Juvéderm, says neither her friends nor her husband of 18 years could pinpoint the reason she looked better: "Everyone just asked if I'd changed my makeup." However, you should also prepare for no reactions at all. "Some patients go in for a round of injections and think everyone is going to tell them how amazing they look," says Sarwer. "They're disappointed if no one notices."

Reasonable patients also know that injectables aren't the flawless-skin Holy Grail. Botox or fillers won't remove dark spots or treat dullness--two things that some studies have shown to be more aging than wrinkles. Nor should they replace a solid skin-care routine of daily sunscreen and nightly anti-agers.

So where did I end up on the Botox question? Well, I'd set up a consultation with my dermatologist and was ready to take the plunge when, smack in the middle of reporting this story, I discovered that my husband and I are expecting our first baby. Since there are no studies tracking the effects of injectables on pregnant women, most doctors (mine included) advise against them while pregnant. So for now, I've found a different solution: bangs. My stylist gave me a fringe that he insisted took off a good five to 10 years. He might be right: When I got my coffee the next morning, the barista, who had long been calling me "ma'am," gave me my venti latte with a "miss."

WANT TO GIVE IT A TRY?

Before you let a needle touch your skin, make sure you...

1. Find a board-certified doctor. "You want a cosmetic dermatologist or plastic surgeon who does several hundred injectable procedures a year," says cosmetic dermatologist Ken Beer, M.D. The American Board of Medical Specialties' site (www.abms.org) lets you search by name to see if a doctor is certified by the American Board of Dermatology or the American Board of Plastic Surgery.

2 .Have a consultation. "It's essential," says Boston dermatologist Ranella Hirsch, M.D., who suggests showing up bare-faced with all of your skin products in tow. "Sometimes it's helpful to try a round of potent topicals first." Also, patients say, get a second opinion. "I'm so glad I did two consults, because the physician I went with used a smaller amount of the injection," says Sherry, 44.

3. Share photos. Ask to see the doctor's before-and-after pictures, especially of patients who are near your age and have a skin type and issues similar to yours. While you're at it, bring along a picture from when you feel you looked your best. This will help you and your doctor get on the same page about what you both mean by "looking younger." Just be reasonable: "If you're 50, bring in a photo of when you were 44, not your wedding picture from 25 years ago," says Hirsch.

DEAL OR NO DEAL?

Beware of discount injectables!

Juvéderm for $100! 50% off Botox! If you shop flash sales, you've seen chirpy offers like these. But every expert we spoke with agrees: Never buy discount injections, because nine times out of 10, they're a "loss leader." Translation: The physician lures you in with a cheapie treatment so he or she can sell you on pricier ones. The only safe bargain is a rebate from your doctor: The manufacturers of neurotoxins and fillers occasionally offer discounts to M.D.s, who then pass along those savings to their patients.

MUSCLE RELAXERS vs. DERMAL FILLERS

WHAT THEY DO

Muscle Relaxers: Neurotoxins (like Botox, Dysport, and Xeomin) block muscles from contracting and causing lines. They can be injected into the forehead and crow's-feet, and between the eyebrows. Dermal Fillers: The various types of fillers can plump up wrinkles and under-eye hollows, lift sagging skin, and enhance lips. They can also replace lost volume, like sunken cheeks.

HOW OFTEN YOU NEED THEM

Muscle Relaxers: Treatments are recommended every four months. A small percentage of Botox patients may develop immunity and find it only lasts a month. That kind of resistance is less likely with Xeomin. Dermal Fillers: Hyaluronic-acid fillers like Juvéderm are most common and last six months or more. Calcium and synthetic formulas (such as Radiesse and Sculptra) can last up to two years.

REPORTED SIDE EFFECTS

Muscle Relaxers: Mild nausea, bruising at the injection sites, and headaches are common but temporary. Dermal Fillers: If injected improperly, neurotoxins can cause temporary eyelid drooping or other facial distortion. If the solution is injected too superficially, you can develop lumps, which usually disappear after a few hours. Larger lumps can be injected with an enzyme that drains them.

HOW MUCH THEY'LL SET YOU BACK

Muscle Relaxers: About $300 per area (e.g., the forehead counts as one area, crow's-feet another). Dermal Fillers: $400 to $1,000 per area. The longer-lasting fillers are higher on the price spectrum.

HOW TO EASE INTO THEM

Muscle Relaxers: Your doctor can dilute the dosage of the neurotoxins for a subtler effect. Dermal Fillers: Try a hyaluronic-acid filler; the results are less dramatic than with synthetics. "It's been a huge mood- and confidence-booster. I spend less time in the mirror judging myself."